Trends in length of stay and short-term outcomes among Medicare patients hospitalized for heart failure, 1993-2006

Predictors of Prolonged Hospital Stay After Microsurgery for Vestibular Schwannoma: Analysis of a Decade of Data

IMPORTANCE

Microsurgical resection is one of the treatments for vestibular schwannomas (VS). While several factors have been linked to increased length of stay (LOS) for VS patients undergoing microsurgery, a better understanding of these factors is important to provide prognostic information for patients.

OBJECTIVE

Determine predictors of increased LOS for VS patients undergoing microsurgical resection.

DESIGN

Retrospective analysis using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2010 to 2020.

SETTING

Database review.

PARTICIPANTS

All patients who underwent microsurgery (CPT codes 61520, 61526/61596) for the management of vestibular schwannoma (ICD9 and ICD10 codes 225.1, D33.3) were included.

MAIN OUTCOMES AND MEASURES

Analyzing perioperative factors that can predict prolonged hospital stay.

RESULTS

A total of 2096 cases were identified and 1,188 (57%) of these patients were female. The mean age was 51.0 ± 14.0 years. Factors contributing to prolonged LOS included African American race (OR = 2.11, 95% CI: 1.32-3.36, p = 0.002), insulin-dependent diabetes mellitus (OR = 2.12, 95% CI: 1.09-4.4.11, p = 0.026), hypertension (OR = 1.26, 95% CI: 1-1.58, p = 0.046), functional dependency (OR = 5.22, 95% CI: 2.31-11.79, p = 0.001), prior steroid use (OR = 1.96, 95% CI: 1.18-3.15, p = 0.009), ASA class III (OR = 2.06, 95% CI: 1.18-3.6, p < 0.011), ASA class IV (OR = 6.34, 95% CI: 2.62-15.33, p < 0.001), and prolonged operative time (OR = 2.14, 95% CI: 1.76-2.61). Microsurgery by a translabyrinthine (TL) approach compared to a retrosigmoid (RSG) approach had lower odds of prolonged LOS (OR = 0.67, 95% CI: 0.54-0.82, p < 0.001). In a separate analysis regarding patients receiving reoperation, operative time was the only predictor of prolonged LOS (OR = 2.77, 95% CI: 1.39-5.53, p = 0.004.).

CONCLUSIONS AND RELEVANCE

Our analysis offers an analysis of the factors associated with a prolonged LOS for the surgical management of VS. By identifying healthcare disparities, targeting modifiable factors, and applying risk stratification based on demographics and comorbidities, we can work toward reducing disparities in LOS and enhancing patient outcomes.

Risk factors for hospitalization-associated disability among older patients: A systematic review and meta-analysis

BACKGROUND

The outcomes of older patients are significantly limited by hospitalization-associated disability (HAD), and there are currently few available management options for HAD. This review aimed to identify and quantify the risk factors for HAD, to provide reliable evidence for developing a HAD prevention program centered on risk factor management among older patients.

METHODS

The MEDLINE, Embase, PsycINFO, CINAHL, and PubMed databases were searched in March 2024 to identify cross-sectional and cohort studies that used multivariable analysis to examine risk factors for HAD among older patients.

RESULTS

We screened 883 studies, 21 of which met our inclusion criteria. Our findings revealed a substantial association between various risk factors and HAD among older patients. Specifically, advanced age, female sex, Caucasian ethnicity, comorbidity burden, better activities of daily living at admission, dementia diagnosis, and longer lengths of stay were significant risk factors for HAD. Furthermore, frailty, poor physical function, immobility, and delirium were identified as confirmed risk factors for HAD among older patients.

CONCLUSIONS

This review provided a comprehensive synthesis of available evidence on risk factors for HAD among older patients, serving as a valuable guide for the development of HAD prevention strategies both prior to and during hospitalization.

Understanding the Perspectives of Key Stakeholders toward Medicare's Home Health Value-Based Purchasing (HHVBP) in the US

OBJECTIVES

This study examines the perspectives of key stakeholders in home health toward Medicare's Home Health Value Based Purchasing (HHVBP) program, piloted among home health agencies (HHAs) in 9 states from 2016 to 2021, and based on initial performance, was expanded to the remaining 41 (nonpilot) states in January 2023.

DESIGN

We conducted semistructured interviews wherein we inquired participants' views toward and experiences with HHVBP. We used convenience and purposive sampling to obtain diversity in HHA size, geography, and quality.

SETTING AND PARTICIPANTS

We conducted interviews from July 2022 to May 2023 with HHA leaders, staff, and clinicians, advocacy and trade organization leaders, and policy experts from pilot and nonpilot states.

METHODS

We used thematic analysis to develop a codebook that included framework-derived, a priori, and inductive codes. We identified key themes and subthemes accordingly.

RESULTS

Forty-seven stakeholders representing 25 unique organizations participated: 22 (47%) from pilot states and 25 (53%) from nonpilot states; of these, 24 (51%) were HHA leaders, 13 (28%) were organizational leaders, and 10 (21%) were clinicians; 26 (55%) were centered in the Northeast, 9 (19%) in the West, 7 (15%) had a national presence, and 5 (11%) were centered across the South. Four key themes emerged. There were (1) wide variations in awareness, understanding, and attitudes toward HHVBP regardless of pilot status or stakeholder type; (2) concerns about aspects of HHVBP, including consequences for HHAs and patients; (3) a range of strategies used by HHAs to address HHVBP; (4) other concurrent issues that HHAs were navigating alongside HHVBP.

CONCLUSIONS AND IMPLICATIONS

Despite HHVBP's national implementation, awareness of and attitudes toward HHVBP varied across stakeholders from pilot and nonpilot states, as did efforts to address it. Although some viewed the policy favorably, others were concerned it could negatively impact HHAs and patients. Understanding the experiences of stakeholders is vital for illuminating the intended and unintended consequences of HHVBP policy.

Tracing In-Hospital COVID-19 Outcomes: A Multistate Model Exploration (TRACE)

This study aims to develop and apply multistate models to estimate, forecast, and manage hospital length of stay during the COVID-19 epidemic without using any external packages. Data from Bellvitge University Hospital in Barcelona, Spain, were analyzed, involving 2285 hospitalized COVID-19 patients with moderate to severe conditions. The implemented multistate model includes transition probabilities and risk rates calculated from transitions between defined states, such as admission, ICU transfer, discharge, and death. In addition to examining key factors like age and gender, diabetes, lymphocyte count, comorbidity burden, symptom duration, and different COVID-19 waves were analyzed. Based on the model, patients hospitalized stay an average of 11.90 days before discharge, 2.84 days before moving to the ICU, or 34.21 days before death. ICU patients remain for about 24.08 days, with subsequent stays of 124.30 days before discharge and 35.44 days before death. These results highlight hospital stays' varying durations and trajectories, providing critical insights into patient flow and healthcare resource utilization. Additionally, it can predict ICU peak loads for specific subgroups, aiding in preparedness. Future work will integrate the developed code into the hospital's Health Information System (HIS) following ISO 13606 EHR standards and implement recursive methods to enhance the model's efficiency and accuracy.

Legal Regulation, Financial Incentives and Professional Autonomy in the Prioritisation of Norwegian Specialist Health Services

To study hospital physicians' awareness and perceptions of the legal and financial regulations, and their impact on professional discretion regarding equity in access to treatment and quality of care. A sample of 637 physicians in the Norwegian specialist healthcare services selected from a survey conducted by the Institute for Studies of the Medical Profession. The paper investigates how legal and financial policy instruments affect the application of professional discretion regarding the prioritisation of specialist health services. Descriptive statistics and regressions were conducted for the analyses. Compared with financial incentives, legal regulations (laws, priority rules and guidelines) were assessed to be less negative external interventions in the exercise of medical and professional judgement. The empirical analyses revealed a positive tendency in physicians' assessments of the impact of legal regulations on treatment equity and healthcare quality, but negative attitudes towards financial instruments. The variations revealed are attributable to various structural and epistemic features of the legal-bureaucratic and economic models of administration in this area of the welfare state. Legal and financial regulations are imposed to achieve certain social goals and values. The findings of this study can provide further insight for the health authorities in other countries concerning implementation of such regulations in the specialist healthcare services.

The Respiratory Rate, Age, and Mean Arterial Pressure (RAM) Index: A Novel Prognostic Tool to Predict Mortality among Adult Patients with Acute Heart Failure in the Emergency Department

Background and Objectives: Acute heart failure (AHF) is a life-threatening condition frequently encountered in the emergency department (ED). Identifying reliable prognostic indicators for in-hospital mortality is crucial for risk stratification and the appropriate management of AHF patients. This study aimed to assess the most effective method for predicting in-hospital mortality among various physiological parameters in patients with AHF presenting to the ED. Additionally, the study evaluated the effectiveness of the RAM index-respiratory rate (RR), age, and mean arterial pressure (MAP)-derived from the shock index (SI) by replacing heart rate with RR, as a novel prognostic tool. This was compared with the SI and its other derivatives to predict in-hospital mortality in adult patients with AHF presenting to the ED. Materials and Methods: This is a retrospective study conducted in the ED of an urban medical center, enrolling adult patients with signs and symptoms of AHF, who met the epidemiological diagnosis criteria, between January 2017 and December 2021. Baseline physiological parameters, including the RR, heart rate, systolic blood pressure, and diastolic blood pressure, were recorded upon ED admission. The RAM index was calculated as the RR multiplied by the age divided by the MAP. Statistical analysis was performed, including univariate analysis, logistic regression, and receiver operating characteristic (ROC) curve analysis. Results: A total of 2333 patients were included in the study. A RAM index > 18.6 (area under ROC curve (AUROC): 0.81; 95% confidence interval (CI): 0.79-0.83) had a superior mortality discrimination ability compared to an SI > 0.77 (AUROC: 0.75; 95% CI: 0.72-0.77), modified shock index > 1.11 (AUROC: 0.75; 95% CI: 0.73-0.77), age shock index > 62.7 (AUROC: 0.74; 95% CI: 0.72-0.76), and age-modified shock index > 79.9 (AUROC: 0.75; 95% CI: 0.73-0.77). A RAM index > 18.6 demonstrated a 7.36-fold higher risk of in-hospital mortality with a sensitivity of 0.80, specificity of 0.68, and negative predictive value of 0.97. Conclusions: The RAM index is an effective tool to predict mortality in AHF patients presenting to the ED. Its superior performance compared to traditional SI-based parameters suggests that the RAM index can aid in risk stratification and the early identification of high-risk patients, facilitating timely and aggressive treatment strategies.

Adiposity modifies the association between heart failure risk and glucose metabolic disorder in older individuals: a community-based prospective cohort study

BACKGROUND

Glucose metabolic disorder is associated with the risk of heart failure (HF). Adiposity is a comorbidity that is inextricably linked with abnormal glucose metabolism in older individuals. However, the effect of adiposity on the association between glucose metabolic disorder and HF risk, and the underlying mechanism remain unclear.

METHODS

A total of 13,251 participants aged ≥ 60 years from a cohort study were categorized into euglycemia, prediabetes, uncontrolled diabetes, and well-controlled diabetes. Adiposity was assessed using body mass index (BMI), waist-to-hip ratio (WHR), and visceral fat area (VFA). Adiposity-associated metabolic activities were evaluated using adiponectin-to-leptin ratio (ALR), homeostatic model assessment of insulin resistance (HOMA-IR), and triglyceride-glucose index (TyG). The first occurrence of HF served as the outcome during the follow-up period.

RESULTS

A total of 1,138 participants developed HF over the course of an average follow-up period of 10.9 years. The rate of incident HF occurrence was higher in prediabetes, uncontrolled diabetes, and well-controlled diabetes participants compared to that in euglycemia participants. However, the high rates were significantly attenuated by BMI, VFA, and WHR. For WHR in particular, the hazard ratio for incident HF was 1.18 (95% confidence interval (CI): 1.03, 1.35, Padj.=0.017) in prediabetes, 1.59 (95% CI: 1.34, 1.90, Padj.<0.001) in uncontrolled diabetes, and 1.10 (95% CI: 0.85, 1.43, Padj.=0.466) in well-controlled diabetes. The population attributable risk percentage for central obesity classified by WHR for incident HF was 30.3% in euglycemia, 50.0% in prediabetes, 48.5% in uncontrolled diabetes, and 54.4% in well-controlled diabetes. Adiposity measures, especially WHR, showed a significant interaction with glucose metabolic disorder in incident HF (all Padj.<0.001). ALR was negatively associated and HOMA-IR and TyG were positively associated with BMI, WHR, VFA, and incident HF (all Padj.<0.05). ALR, HOMA-IR, and TyG mediated the associations for BMI, WHR and VFA with incident HF (all Padj.<0.05).

CONCLUSIONS

Adiposity attenuated the association of glucose metabolic disorder with incident HF. The results also showed that WHR may be an appropriate indicator for evaluating adiposity in older individuals. Adiposity-associated metabolic activities may have a bridging role in the process of adiposity attenuating the association between glucose metabolic disorder and incident HF.

TRIAL REGISTRATION

retrospectively registered number: ChiCTR-EOC-17,013,598.

Prediction of 90 day readmission in heart failure with preserved ejection fraction by interpretable machine learning

AIMS

Certain critical risk factors of heart failure with preserved ejection fraction (HFpEF) patients were significantly different from those of heart failure with reduced ejection fraction (HFrEF) patients, resulting in the limitations of existing predictive models in real-world situations. This study aimed to develop a machine learning model for predicting 90 day readmission for HFpEF patients.

METHODS AND RESULTS

Data were extracted from electronic health records from 1 August 2020 to 1 August 2021 and follow-up records of patients with HFpEF within 3 months after discharge. Feature extraction was performed by univariate analysis combined with the least absolute shrinkage and selection operator (LASSO) algorithms. Machine learning models like eXtreme Gradient Boosting (XGBoost), random forest, neural network and logistic regression were adopted to construct models. The discrimination and calibration of each model were compared, and the Shapley Additive exPlanations (SHAP) method was used to explore the interpretability of the model. The cohort included 746 patients, of whom 103 (13.8%) were readmitted within 90 days. XGBoost owned the best performance [area under the curve (AUC) = 0.896, precision-recall area under the curve (PR-AUC) = 0.868, sensitivity = 0.817, specificity = 0.837, balanced accuracy = 0.827]. The Kolmogorov-Smirnov (KS) statistic was 0.694 at 0.468 in the XGBoost model. SHAP identified the top 12 risk features, including activities of daily living (ADL), left atrial dimension (LAD), left ventricular end-diastolic diameter (LVDD), shortness, nitrates, length of stay, nutritional risk, fall risk, accompanied by other symptoms, educational level, anticoagulants and edema.

CONCLUSIONS

Our model could help medical agencies achieve the early identification of 90 day readmission risk in HFpEF patients and reveal risk factors that provide valuable insights for treatments.

Remote Ischemic Conditioning Improves Cardiovascular Function in Heart Failure Patients

Background

Recently, it has been shown that remote ischemic conditioning (RIC) can be used as a healthy regimen to reverse disease and aging. With this in mind, we are studying the consequences of RIC on cardiovascular function in heart failure patients.

Methods

Forty patients with stable heart failure were prospectively enlisted and randomly divided into RIC (n = 20) and control (n = 20) groups. The RIC protocol consists of a 3-min inflation and then deflation of the blood pressure cuff attached to the upper arm to produce transient ischemia of the arm. RIC treatment was performed once daily for 1 year. NYHA class, left ventricular ejection fraction (LVEF), left atrial and ventricular dimensions were all assessed in two groups.

Results

RIC was well tolerated. After 1 year of treatment, New York Heart Association (NYHA) class improved and LVEF showed a significant increase from 37.11% to 52.44% (P < 0.0001). Additionally, the dimensions of the left atrium (from 50.55 to 43.25 mm) and ventricle (from 53.04 to 50.15 mm) were significantly reduced in the RIC group.

Conclusion

This study suggests that 1 year of RIC treatment as a health strategy could improve cardiovascular function in heart failure patients, leading to its widespread use in these patients.

Gender diversity and healthcare performance: A quantitative analysis from the Italian health system

Unlike many other industries, which are characterized by a more significant presence of men than women, the healthcare sector has a clear majority of women. However, even if at the non-executive level, the percentage of women is extremely higher than that of men, at the executive level, this percentage is completely overturned, generating the so-called glass ceiling effect. Despite extensive research on gender diversity and its impact on financial metrics, few studies have focused on clinical measures. To bridge this research gap, the article analyzes the relationship between gender diversity and healthcare metrics. We developed an econometric model for unbalanced panel data by performing a random effect and a quantile regression analysis, which test the relationship between gender diversity and the average length of stay (LOS), controlling for structural and clinical metrics. We find that, in general, a higher percentage of women in non-executive positions is related to an increase in LOS. Conversely, a higher rate of women in executive positions is related to a lower level of LOS. Empirical evidence supports the relevance of including human resources strategies to increase the number of women at executive managerial positions. However, the study highlights also the necessity to consider how to make the public health sector positions more appealing for men.

Pain, Return to Community Status, and 90-Day Mortality Among Hospitalized Patients With Heart Failure

BACKGROUND

Pain is common among patients with heart failure but has not been examined with short-term discharge outcomes. The purpose was to examine whether pain at discharge predicts return to community status and 90-day mortality among hospitalized patients with heart failure.

METHODS

Data from medical records of 2169 patients hospitalized with heart failure were analyzed in this retrospective cohort study. The independent variable was a diagnosis of pain at discharge. Outcomes were return to community status (yes/no) and 90-day mortality. Logistic regression was used to address aims. Covariates included age, gender, race, vital signs, comorbid symptoms, comorbid conditions, cardiac devices, and length of stay.

RESULTS

The sample had a mean age of 66.53 years, and was 57.4% women and 55.9% Black. Of 2169 patients, 1601 (73.8%) returned to community, and 117 (5.4%) died at or before 90 days. Patients with pain returned to community less frequently (69.6%) compared with patients without pain (75.2%), which was a statistically significant relationship (odds ratio, 0.74; 95% confidence interval, 0.57-0.97; P = .028). Other variables that predicted return to community status included age, comorbid conditions, dyspnea, fatigue, systolic blood pressure, and length of stay. Pain did not predict increased 90-day mortality. Variables that predicted mortality included age, liver disease, and systolic blood pressure.

CONCLUSION

Patients with pain were less likely to return to community but did not have higher 90-day mortality. Pain in combination with other symptoms and comorbid conditions may play a role in mortality if acute pain versus chronic pain can be stratified in a future study.

Vasodilators for Acute Heart Failure - A Systematic Review with Meta-Analysis

BACKGROUND

Acute heart failure is a public health concern. This study systematically reviewed randomized clinical trials (RCTs) to evaluate vasodilators in acute heart failure.

METHODS

The search was conducted across the databases of Medline, Embase, Latin American and the Caribbean Literature on Health Sciences, Web of Science, and the Cochrane Central Register of Controlled Trials. Inclusion criteria consisted of RCTs that compared vasodilators versus standard care, placebo, or cointerventions. The primary outcome was all-cause mortality; secondary outcomes were serious adverse events (SAEs), tracheal intubation, and length of hospital stay. Risk of bias was assessed in all trials.

RESULTS

The study included 46 RCTs that enrolled 28,374 patients with acute heart failure. Vasodilators did not reduce the risk of all-cause mortality (risk ratio, 0.95; 95% confidence interval [CI], 0.87 to 1.04; I2=9.51%; P=0.26). No evidence of a difference was seen in the risk of SAEs (risk ratio, 1.01; 95% CI, 0.97 to 1.05; I2=0.94%) or length of hospital stay (mean difference, -0.10; 95% CI, -0.28 to 0.08; I2=69.84%). Vasodilator use was associated with a lower risk of tracheal intubation (risk ratio, 0.54; 95% CI, 0.30 to 0.99; I2=51.96%) compared with no receipt of vasodilators.

CONCLUSIONS

In this systematic review with meta-analysis of patients with acute heart failure, vasodilators did not reduce all-cause mortality.

Preoperative Risk Factors Impacting Length of Stay After Transcarotid Artery Revascularization

BACKGROUND

Transcarotid artery revascularization (TCAR), using interoperative flow reversal is a unique, hybrid operation utilized in treating critical carotid artery stenosis. Over the past decade, TCAR has been increasingly used to treat asymptomatic carotid artery disease and has a similar risk profile to traditional carotid endarterectomy. Postoperative length of stay (LOS) has a significant impact on cost-effectiveness and quality outcomes in this expanded setting. The objective of this study is to develop a multivariate regression model to identify key preoperative variables and their impact factor on LOS after TCAR for asymptomatic carotid artery stenosis. We hypothesized that high-risk preoperative patient factors historically identified in carotid endarterectomy would similarly impact LOS after TCAR.

METHODS

A multi-institution, retrospective study of all adult patients undergoing TCAR with flow-reversal for intraoperative neuroprotection was performed using the Society for Vascular Surgery Vascular Quality Initiative (VQI) from January 2016 to August 2021. Patients with prolonged preoperative hospitalization (preoperative LOS ≥1 day) were excluded to enhance the capture of carotid artery stenosis as the index admission. Univariate analysis was done on preoperative factors against LOS using nonparametric statistical tests. A multivariate model was then constructed using a negative binomial regression. The study population was split into 80% "training" data for model formulation and 20% "test" data for model validation.

RESULTS

Thirteen thousand four hundred eighty-three patients undergoing TCAR for asymptomatic carotid stenosis met the study's inclusion criteria with a median postoperative LOS of 1.82 days. Factors in VQI found to have a significant effect on LOS and retained in the multivariate model were lesion type (restenosis versus atherosclerotic), age, gender, chronic obstructive pulmonary disease, preoperative beta blocker, calcific lesion burden, hypertension status, and race (P < 0.05). The model accurately predicted LOS after TCAR within 1 day for 86.04% and within 2 days for 94.51% of patients in the test population.

CONCLUSIONS

This large-scale analysis from 2016 to 2021 spans a considerable expansion in the practice of TCAR for asymptomatic carotid disease. All preoperative variables shown to significantly increase the postoperative LOS were derived from the VQI data set. As LOS is a measure of health-care efficiency and cost-effectiveness, this model can be used to identify patients at risk for increased postoperative LOS. It has the potential to be incorporated into a patient/physician decision support tool to optimize resource planning and patient selection for elective TCAR.

Patient Factors Associated With Prolonged Length of Stay After Traumatic Brain Injury

Background For traumatic brain injury (TBI) survivors, recovery can lead to significant time spent in the inpatient/rehabilitation settings. Hospital length of stay (LOS) after TBI is a crucial metric of resource utilization and treatment costs. Risk factors for prolonged LOS (PLOS) after TBI require further characterization. Methodology We conducted a retrospective analysis of patients with diagnosed TBI at an urban trauma center. PLOS was defined as the 95th percentile of the LOS of the cohort. Patients with and without PLOS were compared using clinical/injury factors. Analyses included descriptive statistics, non-parametric analyses, and multivariable logistic regression for PLOS status. Results The threshold for PLOS was >24 days. In the cohort of 1,343 patients, 77 had PLOS. PLOS was significantly associated with longer mean intensive care unit (ICU) stays (16.4 vs. 1.5 days), higher mean injury severity scores (18.6 vs. 13.8), lower mean Glasgow coma scale scores (11.3 vs. 13.7) and greater mean complication burden (0.7 vs. 0.1). PLOS patients were more likely to have moderate/severe TBI, Medicaid insurance, and were less likely to be discharged home. In the regression model, PLOS was associated with ICU stay, inpatient disposition, ventilator use, unplanned intubation, and inpatient alcohol withdrawal. Conclusions TBI patients with PLOS were more likely to have severe injuries, in-hospital complications, and Medicaid insurance. PLOS was predicted by ICU stay, intubation, alcohol withdrawal, and disposition to inpatient/post-acute care facilities. Efforts to reduce in-hospital complications and expedite discharge may reduce LOS and accompanying costs. Further validation of these results is needed from larger multicenter studies.

Effectiveness of a Smartphone App-Based Intervention With Bluetooth-Connected Monitoring Devices and a Feedback System in Heart Failure (SMART-HF Trial): Randomized Controlled Trial

BACKGROUND

Current heart failure (HF) guidelines recommend a multidisciplinary approach, discharge education, and self-management for HF. However, the recommendations are challenging to implement in real-world clinical settings.

OBJECTIVE

We developed a mobile health (mHealth) platform for HF self-care to evaluate whether a smartphone app-based intervention with Bluetooth-connected monitoring devices and a feedback system can help improve HF symptoms.

METHODS

In this prospective, randomized, multicenter study, we enrolled patients 20 years of age and older, hospitalized for acute HF, and who could use a smartphone from 7 tertiary hospitals in South Korea. In the intervention group (n=39), the apps were automatically paired with Bluetooth-connected monitoring devices. The patients could enter information on vital signs, HF symptoms, diet, medications, and exercise regimen into the app daily and receive feedback or alerts on their input. In the control group (n=38), patients could only enter their blood pressure, heart rate, and weight using conventional, non-Bluetooth devices and could not receive any feedback or alerts from the app. The primary end point was the change in dyspnea symptom scores from baseline to 4 weeks, assessed using a questionnaire.

RESULTS

At 4 weeks, the change in dyspnea symptom score from baseline was significantly greater in the intervention group than in the control group (mean -1.3, SD 2.1 vs mean -0.3, SD 2.3; P=.048). A significant reduction was found in body water composition from baseline to the final measurement in the intervention group (baseline level mean 7.4, SD 2.5 vs final level mean 6.6, SD 2.5; P=.003). App adherence, which was assessed based on log-in or the percentage of days when symptoms were first observed, was higher in the intervention group than in the control group. Composite end points, including death, rehospitalization, and urgent HF visits, were not significantly different between the 2 groups.

CONCLUSIONS

The mobile-based health platform with Bluetooth-connected monitoring devices and a feedback system demonstrated improvement in dyspnea symptoms in patients with HF. This study provides evidence and rationale for implementing mobile app-based self-care strategies and feedback for patients with HF.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05668000; https://clinicaltrials.gov/study/NCT05668000.

Impact of Changes in Rectus Femoris Cross-Sectional Area Measured by Ultrasound on the Prognosis of Patients With Acute Heart Failure

BACKGROUND

Low muscle mass in patients with acute heart failure (AHF) is associated with poor prognosis; however, this is based on a single baseline measurement, with little information on changes in muscle mass during hospitalization and their clinical implications. This study investigated the relationship between changes in rectus femoris cross-sectional area (RFCSA) on ultrasound and the prognosis of patients with AHF.

METHODS AND RESULTS

This is a retrospective evaluation of 284 AHF patients (mean [±SD] age 79.1±11.9 years; 116 female). RFCSA assessments at admission (pre-RFCSA), ∆RFCSA (i.e., the percentage change in RFCSA from admission to 2 weeks), and composite prognosis (all-cause death and heart failure-related readmission) within 1 year were determined. Patients were divided into 4 groups according to their median pre-RFCSA and ∆RFCSA after sex stratification: Group A, higher pre-RFCSA/better ∆RFCSA; Group B, higher pre-RFCSA/worse ∆RFCSA; Group C, lower pre-RFCSA/better ∆RFCSA; Group D, lower pre-RFCSA/worse ∆RFCSA. In the Cox regression analysis, with Group A as the reference, the cumulative event rate of Group C (hazard ratio [HR] 3.39; 95% confidence interval [CI] 0.71-16.09; P=0.124) did not differ significantly; however, the cumulative event rates of Group B (HR 7.93; 95% CI 1.99-31.60; P=0.003) and Group D (HR 9.24; 95% CI 2.57-33.26; P<0.001) were significantly higher.

CONCLUSIONS

∆RFCSA during hospitalization is useful for risk assessment of prognosis in patients with AHF.

The genetic association between hyperthyroidism and heart failure: a Mendelian randomization study

Background and aims

Hyperthyroidism is an endocrine disease with multiple etiologies and manifestations. Heart failure (HF) is a common, costly, and deadly medical condition in clinical practice. Numerous studies have suggested that abnormal thyroid function can induce or aggravate the development of heart disease. However, no study has demonstrated a causal relationship between hyperthyroidism and heart failure. Therefore, the purpose of this study was to explore the causal link between hyperthyroidism and HF.

Methods

Summary data for genetically predicted hyperthyroidism were obtained from a genetic association study. The data examined for genetically determined all-cause heart failure came from 218,208 individuals from the FinnGen Consortium. Two-sample Mendelian randomization (MR) analysis was used to estimate the causal link between hyperthyroidism and heart failure. Statistical analyses were conducted using the inverse variance-weighted, weighted median, simple median, weighted mode, MR-PRESSO (number of distribution = 5000), MR-Egger, and leave-one-out.

Results

The results of the inverse-variance weighted analysis indicated a causal association between hyperthyroidism and an increased risk of all-cause heart failure (IVW: β=0.048, OR=1.049, 95%CI: [1.013 to 1.087], P=0.007). Similarly, the weighted median approach demonstrated a positive correlation between hyperthyroidism and all-cause heart failure (OR=1.049, [95% CI, 1.001-1.100]; P=0.044). Additionally, no horizontal pleiotropy or heterogeneity was observed. The leave-one-out analysis revealed that the majority of the SNP-driven associations were not influenced by a single genetic marker.

Conclusion

Our study observed a causal relationship between hyperthyroidism and all-cause heart failure. Hyperthyroidism may associate with heart failure genetically.

Machine learning-based gait analysis to predict clinical frailty scale in elderly patients with heart failure

Aims

Although frailty assessment is recommended for guiding treatment strategies and outcome prediction in elderly patients with heart failure (HF), most frailty scales are subjective, and the scores vary among raters. We sought to develop a machine learning-based automatic rating method/system/model of the clinical frailty scale (CFS) for patients with HF.

Methods and results

We prospectively examined 417 elderly (≥75 years) with symptomatic chronic HF patients from 7 centres between January 2019 and October 2023. The patients were divided into derivation (n = 194) and validation (n = 223) cohorts. We obtained body-tracking motion data using a deep learning-based pose estimation library, on a smartphone camera. Predicted CFS was calculated from 128 key features, including gait parameters, using the light gradient boosting machine (LightGBM) model. To evaluate the performance of this model, we calculated Cohen's weighted kappa (CWK) and intraclass correlation coefficient (ICC) between the predicted and actual CFSs. In the derivation and validation datasets, the LightGBM models showed excellent agreements between the actual and predicted CFSs [CWK 0.866, 95% confidence interval (CI) 0.807-0.911; ICC 0.866, 95% CI 0.827-0.898; CWK 0.812, 95% CI 0.752-0.868; ICC 0.813, 95% CI 0.761-0.854, respectively]. During a median follow-up period of 391 (inter-quartile range 273-617) days, the higher predicted CFS was independently associated with a higher risk of all-cause death (hazard ratio 1.60, 95% CI 1.02-2.50) after adjusting for significant prognostic covariates.

Conclusion

Machine learning-based algorithms of automatically CFS rating are feasible, and the predicted CFS is associated with the risk of all-cause death in elderly patients with HF.

Post-surgical readmission risk factors in otolaryngology/head and neck surgery

BACKGROUND

Otolaryngology patients are a high-readmission-risk group due to the complexity of surgeries, significant alterations to speech and swallowing functions, and high postoperative complications risk.

METHODS

A retrospective review was performed on patients who underwent otolaryngologic surgery at a single-academic-institution between March 2019 and February 2020.

RESULTS

Among 365 discharges, 21 patients had unplanned readmissions within 30 days. On univariable analysis, acute myocardial infarction, number of total comorbidities, prior chemotherapy/radiation, active smoking, airway surgery, and enteral feeding, and on multivariable analysis, prior chemotherapy/radiation and active smoking were identified as significant readmission risk factors. Readmission risk increased from 2.43% to 7.48% and 41.67% with the addition of each risk factor.

CONCLUSION

Nearly 75% of the readmissions were due to potentially preventable reasons. By identifying and proactively intervening on "at risk" patients during the perioperative timeframe, complications and readmission can be reduced, thereby improving the overall quality of care delivered.

Discharge planning and resource utilization for minimizing readmissions in acute exacerbation of chronic heart failure: Insights from an observational study in a community hospital

This cross-sectional study analyzed discharge disposition in 1,584 readmitted patients aged 65 or older with acute exacerbation of chronic heart failure (AECHF) in a large community hospital from April 2021 to April 2022. The study aimed to explore the relationship between age (65-74, 75-85, and 85 or older) and gender (male, female) with discharge disposition. Results revealed that 55.6 % were discharged for home self-care, 27.3 % with external home health support, and 17.1 % to skilled nursing facilities. Logistic regression showed no significant differences in discharge between age groups. Gender also had no statistically significant effect on discharge disposition. Effective discharge planning emerged as a key factor in reducing readmissions for AECHF. Gender did not significantly impact disposition, suggesting other variables played a more pivotal role. Comprehensive discharge planning and resource allocation, tailored to patient needs, are recommended to enhance patient outcomes and lower AECHF readmission rates.

Factors predictive of hospital length of stay in patients with an index episode of acute necrotizing pancreatitis

INTRODUCTION

Acute necrotizing pancreatitis (ANP) complicates 15 % of acute pancreatitis cases and is associated with prolonged length of stay (LOS). There are limited studies exploring potential predictors.

METHODS

We carried out a retrospective study of all consecutive patients presenting to a large referral healthcare system with ANP. Patients younger than 18 years of age, without confirmed glandular necrosis and with in-hospital mortality were excluded. Poisson regression was carried out to identify potential predictors of prolonged hospital stay.

RESULTS

One hundred and sixty-two patients hospitalized between December 2016 and June 2020 were included. The median LOS was 12 days (range: 1-155 days). On multivariate analysis, organ dysfunction at presentation (Incidence rate ratio (IRR) 1.21, p = 0.01) or during admission (IRR 1.32, p = 0.001), Charlson Comorbidity Index scores (IRR 1.1 per CCI point, p < 0.001), known chronic pancreatitis (IRR 1.19, p = 0.03), concurrent (non-pancreas related) infections (IRR 1.13, p = 0.04), need for enteral tube placement (IRR 3.42, p < 0.001) and in-hospital interventions (IRR 1.48-2.85 depending on intervention, p < 0.001) were associated with increased LOS. For patients in the cohort to whom this applied, delayed hospital transfers (IRR 1.02, p < 0.001) and delayed start of enteral feeds (IRR 1.01, p = 0.017) contributed to increased overall LOS.

CONCLUSION

We demonstrate that multiple factors including delayed transfers to hospitals with pancreaticobiliary expertise lead to increased length of hospitalization. We suggest various strategies that can be considered to target those gaps and may have a favorable effect on LOS.

Application of machine learning models on predicting the length of hospital stay in fragility fracture patients

BACKGROUND

The rate of geriatric hip fracture in Hong Kong is increasing steadily and associated mortality in fragility fracture is high. Moreover, fragility fracture patients increase the pressure on hospital bed demand. Hence, this study aims to develop a predictive model on the length of hospital stay (LOS) of geriatric fragility fracture patients using machine learning (ML) techniques.

METHODS

In this study, we use the basic information, such as gender, age, residence type, etc., and medical parameters of patients, such as the modified functional ambulation classification score (MFAC), elderly mobility scale (EMS), modified Barthel index (MBI) etc, to predict whether the length of stay would exceed 21 days or not.

RESULTS

Our results are promising despite the relatively small sample size of 8000 data. We develop various models with three approaches, namely (1) regularizing gradient boosting frameworks, (2) custom-built artificial neural network and (3) Google's Wide & Deep Learning technique. Our best results resulted from our Wide & Deep model with an accuracy of 0.79, with a precision of 0.73, with an area under the receiver operating characteristic curve (AUC-ROC) of 0.84. Feature importance analysis indicates (1) the type of hospital the patient is admitted to, (2) the mental state of the patient and (3) the length of stay at the acute hospital all have a relatively strong impact on the length of stay at palliative care.

CONCLUSIONS

Applying ML techniques to improve the quality and efficiency in the healthcare sector is becoming popular in Hong Kong and around the globe, but there has not yet been research related to fragility fracture. The integration of machine learning may be useful for health-care professionals to better identify fragility fracture patients at risk of prolonged hospital stays. These findings underline the usefulness of machine learning techniques in optimizing resource allocation by identifying high risk individuals and providing appropriate management to improve treatment outcome.

Reducing the hospitalization epidemic of chronic heart failure by disease management programs

Chronic heart failure is the most common cause of hospitalization in Europe and rates are steadily increasing due to aging of the population. Hospitalization identifies a fundamental change in the natural history of heart failure (HF) increasing the risk of re-hospitalization and mortality. Heart failure management programs improve the quality of care for HF patients and reduce hospitalization burden. The goals of the heart failure management programs include optimization of drug therapy, patient education, early recognition of signs of decompensation, and management of comorbidities. Randomized clinical trials evidenced that system of care for heart failure patients improved adherence to treatment and reduced unplanned re-admissions to hospital. Multidisciplinary programs and home-visiting have shown improved efficacy with reductions in HF and all-cause hospitalizations and mortality. Community HF clinics should take care of the management of stable patients in strict contact with primary care, while hospital out-patients clinics should care of patients with severe disease or persistent clinical instability, candidates to advanced treatment options. In any case a holistic, patient-centered approach is suggested, to optimize care considering the needs of the individual patient. Telemonitoring is a new opportunity for HF patients, because it allows the continuity of care at home. All heart failure patients should require follow-up in a specific management program, but most of date come from clinical trials that included high-risk patients. While clinical trials have a specified duration (from months to some years), lifelong follow-up is recommended with differentiated approaches according to the patient's need.

Association of living alone with clinical outcomes in patients with heart failure: A systematic review and meta-analysis

Living alone is an objective sign of social isolation. It is uncertain whether living alone worsens clinical outcomes in heart failure (HF) patients. We aimed to assess how living alone affected clinical outcomes in individuals with HF. We searched the electronic databases of PubMed, Embase, and Cochrane from 1990 to April 2022 for studies comparing living alone with HF. A random-effects model with inverse variance was used to pool adjusted hazard ratios (HRs) and 95% confidence intervals (CIs). Seven studies were deemed to meet the standards. In patients with HF, compared with living with others, living alone was associated with an elevated risk of any hospitalization at the 30-day (HR: 1.78, 95% CI: 1.09-2.89), 90-day (HR: 1.24, 95% CI: 1.02-1.51), or ≥1-year (HR: 1.14, 95% CI: 1.04-1.26) follow-up periods. HF patients living alone also had a greater risk of any hospitalization or death at the 30-day (HR: 1.56, 95% CI: 1.15-2.11), 90-day (HR: 1.26, 95% CI: 1.05-1.50), and ≥1-year (HR: 1.18, 95% CI: 1.09-1.28) follow-up periods. However, patients living alone had no increased risk of all-cause death at the 30-day (HR: 1.0, 95% CI: 0.19-5.36), 90-day (HR: 0.46, 95% CI: 0.03-7.42), or ≥ 1-year (HR: 1.10, 95% CI: 0.73-1.67) follow-up periods. In comparison to living with others, living alone was associated with an increased risk of any hospitalization but not all-cause death in HF patients.

MEESSI-AHF score to estimate short-term prognosis of acute heart failure patients in the Emergency Department: a prospective and multicenter study

BACKGROUND

The assessment of acute heart failure (AHF) prognosis is primordial in emergency setting. Although AHF management is exhaustively codified using mortality predictors, there is currently no recommended scoring system for assessing prognosis. The European Society of Cardiology (ESC) recommends a comprehensive assessment of global AHF prognosis, considering in-hospital mortality, early rehospitalization rates and the length of hospital stay.

OBJECTIVE

We aimed to prospectively evaluate the performance of the Multiple Estimation of risk based on the Emergency department Spanish Score In patients with AHF (MEESSI-AHF) score in estimating short prognosis according to the ESC guidelines.

DESIGN, SETTINGS AND PATIENTS

A multicenter study was conducted between November 2020, and June 2021. Adult patients who presented to eleven French hospitals for AHF were prospectively included.

OUTCOME MEASURES AND ANALYSIS

According to MEESSI-AHF score, patients were stratified in four categories corresponding to mortality risk: low-, intermediate-, high- and very high-risk groups. The primary outcome was the number of days alive and out of the hospital during the 30-day period following admission to the Emergency Department (ED).

RESULTS

In total, 390 patients were included. The number of days alive and out of the hospital decreased significatively with increasing MEESSI-AHF risk groups, ranging from 21.2 days (20.3-22.3 days) for the low-risk, 20 days (19.3-20.5 days) for intermediate risk,18.6 days (17.6-19.6 days) for the high-risk and 17.9 days (16.9-18.9 days) very high-risk category.

CONCLUSION

Among patients admitted to ED for an episode of AHF, the MEESSI-AHF score estimates with good performance the number of days alive and out of the hospital.

Anatomical characterization of pulmonary artery and implications to pulmonary artery pressure monitor implantation

In patients with heart failure, guideline directed medical therapy improves outcomes and requires close patient monitoring. Pulmonary artery pressure monitors permit remote assessment of cardiopulmonary haemodynamics and facilitate early intervention that has been shown to decrease heart failure hospitalization. Pressure sensors implanted in the pulmonary vasculature are stabilized through passive or active interaction with the anatomy and communicate with an external reader to relay invasively measured pressure by radiofrequency. A body mass index  > 35 kg/m2 and chest circumference > 165 cm prevent use due to poor communication. Pulmonary vasculature anatomy is variable between patients and the pulmonary artery size, angulation of vessels and depth of sensor location from the chest wall in heart failure patients who may be candidates for pressure sensors remains largely unexamined. The present study analyses the size, angulation, and depth of the pulmonary artery at the position of implantation of two pulmonary artery pressure sensors: the CardioMEMS sensor typically implanted in the left pulmonary artery and the Cordella sensor implanted in the right pulmonary artery. Thirty-four computed tomography pulmonary angiograms from patients with heart failure were analysed using the MIMICS software. Distance from the bifurcation of the pulmonary artery to the implant site was shorter for the right pulmonary artery (4.55 ± 0.64 cm vs. 7.4 ± 1.3 cm) and vessel diameter at the implant site was larger (17.15 ± 2.87 mm vs. 11.83 ± 2.30 mm). Link distance (length of the communication path between sensor and reader) was shorter for the left pulmonary artery (9.40 ± 1.43 mm vs. 12.54 ± 1.37 mm). Therefore, the detailed analysis of pulmonary arterial anatomy using computed tomography pulmonary angiograms may alter the choice of implant location to reduce the risk of sensor migration and improve readability by minimizing sensor-to-reader link distance.

Which frailty tool best predicts morbidity and mortality in ambulatory patients with heart failure? A prospective study

BACKGROUND

Frailty is common in patients with heart failure (HF) and is associated with adverse outcome, but it is uncertain how frailty should best be measured.

OBJECTIVES

To compare the prognostic value of commonly-used frailty tools in ambulatory patients with HF.

METHODS AND RESULTS

We assessed, simultaneously, three screening tools [clinical frailty scale (CFS); Derby frailty index (DFI); acute frailty network (AFN) frailty criteria), three assessment tools (Fried criteria; Edmonton frailty score (EFS); deficit index (DI)) and three physical tests (handgrip strength, timed get-up-and-go test (TUGT), 5-metre walk test (5MWT)] in consecutive patients with HF attending a routine follow-up visit. 467 patients (67% male, median age = 76 years, median NT-proBNP = 1156 ng/L) were enrolled. During a median follow-up of 554 days, 82 (18%) patients died and 201 (43%) patients were either hospitalised or died. In models corrected for age, Charlson score, haemoglobin, renal function, sodium, NYHA, atrial fibrillation (AF), and body mass index, only log[NT-proBNP] and frailty were independently associated with all-cause death. A base model for predicting mortality at 1 year including NYHA, log[NT-proBNP], sodium and AF, had a C-statistic = 0.75. Amongst screening tools: CFS (C-statistic = 0.84); amongst assessment tools: DI (C-statistic = 0.83) and amongst physical test: 5MWT (C-statistic = 0.80), increased model performance most compared with base model (P <0.05 for all).

CONCLUSION

Frailty is strongly associated with adverse outcomes in ambulatory patients with HF. When added to a base model for predicting mortality at 1 year including NYHA, NT-proBNP, sodium, and AF, CFS provides comparable prognostic information with assessment tools taking longer to perform.

A nationwide study of temporal trends of cause-specific hospital readmissions in patients with heart failure

AIMS

The impact of hospital readmissions on the outcomes of heart failure (HF) patients is well known. However, data on temporal trends of cause-specific hospital readmissions in these patients are limited.

METHODS AND RESULTS

From 1987 to 2014, we identified and followed up for 1 year 608 135 patients ≥18 years hospitalized with HF according to the International Classification of Diseases (ICD) 9 and 10 from the National Inpatient Register. Readmissions for cardiovascular (CVD) and non-CVD causes and co-morbidities were defined according to ICD-9 and ICD-10 codes. We analysed trends in the incidence rate of readmissions, the median time to the first rehospitalization, and the time to readmission, stratified by sex, age groups and cause of rehospitalization using linear regression. During our study, 1 year all-cause mortality decreased (β = -4.93, P < 0.0001), but the incidence rate of readmissions per 1000 person-years remained unchanged. The readmission rate for CVD causes decreased; in contrast, the readmission rate increased across all age and sex groups for non-CVD causes. Analysing the patients by study periods (1987-1997, 1998-2007 and 2008-2014), CVD and non-CVD co-morbidities had a statistically significant increasing trend (P < 0.001). The median time in hospital decreased and the median time to the first readmission were almost unchanged.

CONCLUSIONS

Contrary to a declining mortality rate, the incidence rate of readmissions saw no change, possibly because of divergent trends in cause-specific readmissions. An increasing rate of readmissions for non-CVD causes underscores the importance of optimising multimorbidity management to reduce the risk of readmissions in patients with HF.

Impact of Trimetazidine on the Incident Heart Failure After Coronary Artery Revascularization

ABSTRACT

Abnormal myocardial metabolism is a common pathophysiological process underlying ischemic heart disease and heart failure (HF). Trimetazidine is an antianginal agent with a unique mechanism of action that regulates myocardial energy metabolism and might have a beneficial effect in preventing HF in patients undergoing myocardial revascularization. We aimed to evaluate the potential benefit of trimetazidine in preventing incident hospitalization for HF after myocardial revascularization. Using the common data model, we identified patients without prior HF undergoing myocardial revascularization from 8 hospital databases in Korea. To compare clinical outcomes using trimetazidine, database-level hazard ratios (HRs) were estimated using large-scale propensity score matching for each database and pooled using a random-effects model. The primary outcome was incident hospitalization for HF. The secondary outcome of interest was major adverse cardiac events (MACEs). After propensity score matching, 6724 and 11,211 patients were allocated to trimetazidine new-users and nonusers, respectively. There was no significant difference in the incidence of hospitalization for HF between the 2 groups (HR: 1.08, 95% confidence interval [CI], 0.88-1.31; P = 0.46). The risk of MACE also did not differ between the 2 groups (HR: 1.07, 95% CI, 0.98-1.16; P = 0.15). In conclusion, the use of trimetazidine did not reduce the risk of hospitalization for HF or MACE in patients undergoing myocardial revascularization. Therefore, the role of trimetazidine in contemporary clinical practice cannot be expanded beyond its current role as an add-on treatment for symptomatic angina.

Cardiovascular and renal effects of SGLT2 inhibitor initiation in acute heart failure: a meta-analysis of randomized controlled trials

BACKGROUND

We sought to compare cardiovascular outcomes, renal function, and diuresis in patients receiving standard diuretic therapy for acute heart failure (AHF) with or without the addition of SGLT2i.

METHODS AND RESULTS

Systematic search of three electronic databases identified nine eligible randomized controlled trials involving 2,824 patients. The addition of SGLT2i to conventional therapy for AHF reduced all-cause death (odds ratio [OR] 0.75; 95% CI 0.56-0.99; p = 0.049), readmissions for heart failure (HF) (OR 0.54; 95% CI 0.44-0.66; p < 0.001), and the composite of cardiovascular death and readmissions for HF (hazard ratio 0.71; 95% CI 0.60-0.84; p < 0.001). Furthermore, SGLT2i increased mean daily urinary output in liters (mean difference [MD] 0.45; 95% CI 0.03-0.87; p = 0.035) and decreased mean daily doses of loop diuretics in mg of furosemide equivalent (MD -34.90; 95% CI [- 52.58, - 17.21]; p < 0.001) without increasing the incidence worsening renal function (OR 0.75; 95% CI 0.43-1.29; p = 0.290).

CONCLUSION

SGLT2i addition to conventional diuretic therapy reduced all-cause death, readmissions for HF, and the composite of cardiovascular death or readmissions for HF. Moreover, SGLT2i was associated with a higher volume of diuresis with a lower dose of loop diuretics.

Risk prediction models for mortality and readmission in patients with acute heart failure: A protocol for systematic review, critical appraisal, and meta-analysis

INTRODUCTION

A considerable number of risk models, which predict outcomes in mortality and readmission rates, have been developed for patients with acute heart failure (AHF) to help stratify patients by risk level, improve decision making, and save medical resources. However, some models exist in a clinically useful manner such as risk scores or online calculators, while others are not, providing only limited information that prevents clinicians and patients from using them. The reported performance of some models varied greatly when predicting at multiple time points and being validated in different cohorts, which causes model users uncertainty about the predictive accuracy of these models. The foregoing leads to users facing difficulties in the selection of prediction models, and even sometimes being reluctant to utilize models. Therefore, a systematic review to assess the performance at multiple time points, applicability, and clinical impact of extant prediction models for mortality and readmission in AHF patients is essential. It may facilitate the selection of models for clinical implementation.

METHOD AND ANALYSIS

Four databases will be searched from their inception onwards. Multivariable prognostic models for mortality and/or readmission in AHF patients will be eligible for review. Characteristics and the clinical impact of included models will be summarized qualitatively and quantitatively, and models with clinical utility will be compared with those without. Predictive performance measures of included models with an analogous clinical outcome appraised repeatedly, will be compared and synthesized by a meta-analysis. Meta-analysis of validation studies for a common prediction model at the same time point will also be performed. We will also provide an overview of critical appraisal of the risk of bias, applicability, and reporting transparency of included studies using the PROBAST tool and TRIPOD statement.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number CRD42021256416.

Decreasing Goal Oxygen Saturations in Bronchiolitis Is Associated With Decreased Length of Stay

OBJECTIVES

For patients hospitalized with bronchiolitis, many hospitals have implemented clinical practice guidelines to decrease variability in care. Our hospital updated its bronchiolitis clinical pathway by lowering goal oxygen saturation from 90% to 88%. We compared clinical outcomes before and after this change within the context of the pathway update.

METHODS

This was a retrospective analysis of patients <24 months old admitted to a pediatric tertiary care center from 2019 to 2021 with bronchiolitis. Patients with congenital heart disease, asthma, home oxygen, or admitted to an ICU were excluded. The data were stratified for patients admitted before and after the clinical pathway update. Statistical methods consisted of 2 group comparisons using the χ-square test for categorical variables, the Wilcoxon rank-sum test for continuous variables, and multiple regression analysis.

RESULTS

A total of 1386 patients were included, 779 preupdate and 607 postupdate. There was no statistically significant difference in the admission rate of patients presenting to the emergency department with bronchiolitis between the 2 groups (P value .60). The median time to room air was 40.0 hours preupdate versus 30.0 hours postupdate (P value < .001). The median length of stay was 48.0 hours preupdate versus 41.0 hours postupdate (P value < .001). Readmission rate was 2.7% within 7 days of discharge preupdate, and 2.1% postupdate (P value .51).

CONCLUSIONS

Decreasing goal oxygen saturation to 88% was associated with a statistically significant decrease in time spent on oxygen and length of stay for patients admitted with bronchiolitis with no increase in readmissions.

Pattern of Surgical Diseases Affecting Females in a Teaching Hospital in Central India: A Demographic Study

Introduction  Despite progress in eliminating the social and health disparity between men and women during the last century, gender equality remains an elusive goal, particularly in the developing world. This gender-based bias has been found to directly result into poor health outcome in females. Hence, it is vital to know the number and pattern of surgical diseases affecting females in any setup, so as to improve their admission rates and reach out to this neglected half of population. Materials and Methods  This was a demographic study done at a teaching hospital in Central India from January to June 2020. Data of patients discharged from female surgery ward were collected from medical record department. Age, diagnosis, urban-rural distribution, and length of hospital stay of patients were noted, and data were analyzed statistically. Results  A total of 187 patient records were studied, which revealed that the mean age of the patients was 40.35 years; maximum patients were of gastrointestinal surgery (53.42%) in which the most common diagnosis was cholelithiasis (25.13%). Urological diseases (15.50%), breast diseases (12.83%), perianal disease (9.09%), and thyroid diseases (5.34%) were found in decreasing order of frequency. Overall hospital stays of patients ranged from 1 to 14 days with average stay of 6.35 days. Conclusion  In our study, cholelithiasis was found to be the most common surgically treated disease followed by urological diseases. Breast symptoms, although commonly affecting females, did not turn into admissions as there remains a social taboo attached to it. Breast cancer still presents late, despite being the most common cancer in females in India. Approximately 65% patients were discharged within first 5 days of their admission, which indicates good hospital care and improves patient satisfaction levels. Still there is greater need for public health efforts to improve the monitoring, safety, and availability of surgical services to female patients.

Structural components for the development of a heart failure network

Diagnosis and treatment of heart failure (HF) is challenging, and development of specialized HF networks is mandatory to warrant broad access to guideline directed therapies for patients. Numerous national cardiovascular societies recommend a three-level association of health care providers. This comprises tertiary academic centres, specialized HF clinics and specialized general cardiologists to cover the large spectrum of HF severity and entities. Although this idea of a multi-level care is widely accepted, optimal approach to build and implement a HF network service needs further definition. The core principle is that of network healthcare facilities that also consider regional peculiarities and that implements academic standards, quality indicators (QIs), interdisciplinarity and reimbursement strategies. These determinants of trans-sectoral healthcare need to be embedded in a network that provides sustainability and that incorporates QIs to objectify the efficacy of specific measures. The basis of a HF-network should be a certification system of the respective national HF association to warrant guideline standards and to prevent development of regional hierarchies or dependencies between members. This nationwide framework needs to be complemented by a federal system of regional networks, which also takes local demands into account. These regional units should incorporate digital communication and interaction pathways, structured educational programmes, certified telehealth concepts and follow-up algorithms to meet the requirements of sustainability and efficacy. We here summarize different components of HF networks and introduce the structure and development philosophy of the RUHR-HF-network that constitutes the first certified HF-clinics-network in the Ruhr area-the largest metropolitan area in Germany.

The Effect of Modifiable Risk Factors on Postoperative Complications in Lumbar Spine Fusions

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

The impact of modifiable risk factors (MRFs) on complications, costs, and readmission rates at 30, 90, and 180-days following lumbar spine fusion.

METHODS

Patients with lumbar spine fusions within the 2016-2017 Nationwide Readmissions Database (NRD). Patients were stratified by the following MRFs: Alcohol use, tobacco/nicotine use, nutritional malnourishment, dyslipidemia, and primary hypertension. Differences in complications, non-elective readmission rates, costs, and length of stay were compared between MRFs and the non-MRF group. Statistical analysis was conducted using Tukey multiple comparisons of means, 1-way ANOVA, Wald testing, unpaired Welch 2-sample t-tests, multivariate analysis, and predictive modeling.

RESULTS

The final analysis included 297,579 lumbar fusion patients. At 30 and 90 days, patients with nutritional malnutrition, dyslipidemia, and primary hypertension had significantly greater readmission rates than patients without MRFs (all P<0.01). At 180-days, all MRFs had significantly greater readmission rates than the non-MRF group (all P<0.001). Dyslipidemia demonstrated significantly greater rates of myocardial infarction at 90 days compared to all groups (all P<0.02). Nutritional malnutrition was associated with a significantly greater mortality rate than primary hypertension, non-MRF, and tobacco/nicotine use at 90 days (P<0.001) and only tobacco/nicotine use at 180 days (P=0.007). Predictive modeling showed increases of 0.77%, 1.70%, and 2.44% risk of readmission at 30, 90, and 180-days respectively per additional MRF (all P<0.001).

CONCLUSIONS

These findings highlight the negative impact each MRF has on patients following lumbar spinal fusion. Further longitudinal research is necessary to comprehensively characterize the effects of various MRFs on spine surgery outcomes.

Using routine healthcare data to determine the factors associated with hospital length of stay for hypertensive inpatients in Ghana, 2012-2017

OBJECTIVE

Hospitalisation for hypertension continues to rise in Ghana. It has been revealed that in Ghana, patients hospitalised for hypertension spend between 1 and 91 days on admission. This study therefore sought to estimate the hospital length of stay (LoS) of hypertensive patients and individual or health-related factors that may influence the hospitalisation duration in Ghana.

METHODS

We employed a retrospective study design that used routinely collected health data on hospitalised hypertensive patients in Ghana from the District Health Information Management System database between 2012 and 2017 to model LoS using survival analysis. The cumulative incidence function for discharge stratified by sex was computed. To investigate the factors that influence hospitalisation duration, multivariable Cox regression was used.

RESULTS

Out of a total of 106 372 hypertension admissions, about 72 581 (68.2%) were women. The mean age of the patients was 55.3 (SD=17.5) years. Overall, the median LoS was 3 days with almost 90% of all patients being discharged by the 10th day of admission. Patients admitted in Volta region (HR: 0.89, p<0.001) and Eastern region (HR: 0.96, p=0.002) experienced late discharge as compared with patients admitted in Greater Accra. It was revealed that women (HR: 1.09, p<0.001) were discharged earlier than men. However, having a surgical procedure (HR: 1.07, p<0.001) and having comorbidities such as diabetes (HR: 0.76, p<0.001) and cardiovascular diseases other than hypertension (HR: 0.77, p<0.001) increased the LoS of patients.

CONCLUSION

This study provides the first comprehensive assessment of factors influencing hospitalisation duration of admissions due to hypertension in Ghana. Female sex, all regions except Volta region and Eastern region, experienced early discharge. However, patients with a surgical intervention and comorbidity experienced late discharge.

Caregiving and changes in health-related behaviour

Potential health risks for informal caregivers have been hypothesised to be partly related to adverse changes in health-related behaviour, but evidence is limited. We examined whether smoking, drinking, eating, physical activity or leisure pursuits change in relation to co-resident or out-of-home caregiving (for someone outside the household), and if associations differ by sex, educational attainment, and welfare state typology. We conducted a longitudinal study using six waves of the Survey of Health, Ageing and Retirement in Europe, collecting data repeatedly from 2004 to 2017 for adults aged 50 years and older living in 17 European countries (57,962 individuals). To control for measured and unmeasured within-individual time-invariant confounders, we used fixed effects logistic models to analyse the repeated measures of caregiving, behaviour and covariates and estimated odds ratios (OR) with 95% confidence intervals (95%CI). Among male participants, unhealthy eating increased while smoking decreased [ORs 1.26 (95%CI 1.01-1.58) and 0.53 (0.36-0.78), respectively] in survey waves in which they provided co-resident care, compared with the waves that they did not. Among female participants, there was little change in behaviour between waves with and without co-resident caregiving. When providing out-of-home care, lacks of physical activity and leisure pursuits declined. But in the same time, drinking increased both men and women, and especially among individuals with lower educational attainment and residing in non-Nordic countries. To conclude, overall, increased drinking when providing out-of-home care was most consistent, especially among individuals with lower educational attainment and residing in non-Nordic countries. Otherwise, the associations varied by the type of care, behaviour and population subgroups. These findings indicated that not all caregivers are susceptible to behavioural changes, and that not all behaviour may be involved similarly in linking caregiving to health risks. This opens possibilities to target specific behaviour and groups to prevent adverse changes in health behaviour in caregivers.

The Lateral Femoral Cutaneous and Over the Hip (LOH) Block for the Surgical Management of Hip Fractures: A Safe and Effective Anesthetic Strategy

OBJECTIVES

To examine the efficacy of regional anesthesia with sedation only for a variety of hip fractures using the newly described lateral femoral cutaneous with over the hip (LOH) block.

DESIGN

Retrospective.

SETTING

Orthopedic specialty hospital.

PATIENTS/PARTICIPANTS

40 patients who presented between November 2021 and February 2022 for fixation of OTA/AO 31.A1-3 and 31.B1-3 fractures. Matched cohorts of 40 patients who received general anesthesia and 40 patients who received spinal anesthesia for hip fracture fixation were also used.

INTERVENTION

Operative fixation under LOH block and sedation only. The LOH block is a regional hip analgesic that targets the lateral femoral cutaneous nerve, articular branches of femoral nerve, and accessory obturator nerve.

MAIN OUTCOME MEASUREMENTS

Demographics, intraoperative characteristics, anesthesia-related complications, hospital quality metrics, and short-term mortality and reoperation rates.

RESULTS

A total of 120 patients (40 each: general, spinal, and LOH block) were compared. The cohorts were similar in age, race, body mass index, sex, Charlson comorbidity index, trauma risk score, ambulatory status at baseline, fracture type, and surgical fixation technique performed. Physiologic parameters during surgery were more stable in the LOH block cohort ( P < 0.05). Total OR time and anesthesia time were the shortest for the LOH block cohort ( P < 0.05). Patients in the LOH block cohort also had lower postoperative pain scores ( P < 0.05). Length of hospital stay was the shortest for patients in the LOH block cohort ( P < 0.05), and during discharge, patients in the LOH block cohort ambulated the furthest ( P < 0.05). No differences were found for anesthesia-related complications, palliative care consults, major and minor hospital complications, discharge disposition, reoperation and readmission rates, and mortality rates.

CONCLUSIONS

The LOH block is safe and effective anesthesia for the treatment of all types of hip fractures in the elderly patients requiring surgery. In addition, this block may decrease postoperative pain and length of hospital stay, and allow for greater ambulation in the early postoperative period for patients with hip fracture.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Trial of an Intervention to Improve Acute Heart Failure Outcomes

BACKGROUND

Patients with acute heart failure are frequently or systematically hospitalized, often because the risk of adverse events is uncertain and the options for rapid follow-up are inadequate. Whether the use of a strategy to support clinicians in making decisions about discharging or admitting patients, coupled with rapid follow-up in an outpatient clinic, would affect outcomes remains uncertain.

METHODS

In a stepped-wedge, cluster-randomized trial conducted in Ontario, Canada, we randomly assigned 10 hospitals to staggered start dates for one-way crossover from the control phase (usual care) to the intervention phase, which involved the use of a point-of-care algorithm to stratify patients with acute heart failure according to the risk of death. During the intervention phase, low-risk patients were discharged early (in ≤3 days) and received standardized outpatient care, and high-risk patients were admitted to the hospital. The coprimary outcomes were a composite of death from any cause or hospitalization for cardiovascular causes within 30 days after presentation and the composite outcome within 20 months.

RESULTS

A total of 5452 patients were enrolled in the trial (2972 during the control phase and 2480 during the intervention phase). Within 30 days, death from any cause or hospitalization for cardiovascular causes occurred in 301 patients (12.1%) who were enrolled during the intervention phase and in 430 patients (14.5%) who were enrolled during the control phase (adjusted hazard ratio, 0.88; 95% confidence interval [CI], 0.78 to 0.99; P = 0.04). Within 20 months, the cumulative incidence of primary-outcome events was 54.4% (95% CI, 48.6 to 59.9) among patients who were enrolled during the intervention phase and 56.2% (95% CI, 54.2 to 58.1) among patients who were enrolled during the control phase (adjusted hazard ratio, 0.95; 95% CI, 0.92 to 0.99). Fewer than six deaths or hospitalizations for any cause occurred in low- or intermediate-risk patients before the first outpatient visit within 30 days after discharge.

CONCLUSIONS

Among patients with acute heart failure who were seeking emergency care, the use of a hospital-based strategy to support clinical decision making and rapid follow-up led to a lower risk of the composite of death from any cause or hospitalization for cardiovascular causes within 30 days than usual care. (Funded by the Ontario SPOR Support Unit and others; COACH ClinicalTrials.gov number, NCT02674438.).

Impact of suspected adverse drug reactions on mortality and length of hospital stay in the hospitalised patients: a meta-analysis

PURPOSE

To estimate the risk of mortality and length of stay in hospitalised patients who have experienced suspected adverse drug reactions (ADRs) as compared to patients who did not experience suspected ADRs.

METHODS

A systematic literature search was conducted on databases for observational and randomised controlled studies conducted in any inpatient setting that reported deaths and/or length of hospital stay in patients who had suspected ADRs and did not have suspected ADRs during hospitalisation. PRISMA guidelines were strictly followed during the review. The methodological quality of included studies was assessed using a tool designed by Smyth et al. for the studies of adverse drug reactions. The meta-analytic summary of all-cause mortality was estimated using odds ratio-OR (95% CI) and length of stay using mean difference-MD (95% CI). Both outcomes were pooled using a random effect model (DerSimonian and Laird method). Subgroup and meta-regression were performed based on study variables: study design, age group, study ward, study region, types of suspected ADRs (ADR_Ad-suspected ADRs that lead to hospitalisation and ADR_In-suspected ADRs that occur following hospitalisation), study duration, sample size and study period. The statistical analysis was conducted through the 'Review manager software version 5.4.1 and JASP (Version 0.14.1)'.

RESULTS

After screening 475 relevant articles, 55 studies were included in this meta-analysis. Patients having suspected ADRs had reported significantly higher odds of all-cause mortality [OR: 1.50 (95% CI: 1.21-1.86; I² = 100%) than those patients who did not have suspected ADRs during hospitalisation. Study wards, types of suspected ADRs and sample size were observed as significant predictors of all-cause mortality (p < 0.05). Patients having suspected ADRs had reported significantly higher mean difference in hospital stay [MD: 3.98 (95% CI: 2.91, 5.05; I² = 99%) than those patients who did not have suspected ADRs during hospitalisation. Types of suspected ADRs and study periods were observed as significant predictors of length of stay (p < 0.05).

CONCLUSION

Suspected ADRs significantly increase the risk of mortality and length of stay in hospitalised patients.

SYSTEMATIC REVIEW REGISTRATION

CRD42020176320.

Fever and hypothermia do not affect the all-cause 30-day hospital readmission

BACKGROUND

One of the goals of the Affordable Care Act is to decrease hospital readmissions. While widely adhered to, there is no published research to support the practice of delaying discharge if patients exhibit fever or hypothermia in the preceding 24 h, which is the focus of our study.

METHODS

Retrospective analysis of the minimal (Tmin) and maximal (Tmax) body temperatures collected during the last 24 h before discharge of 19,038 inpatients. Fever was defined as Tmax >99.5F (+1SD from the mean Tmax) or >100.2F (+2SDs), and hypothermia as Tmin <97.1F (-1SD from the mean Tmin) or <96.7F (-2SDs).

RESULTS

The overall readmission rate was 10.2% (highest for General Medicine and Pediatrics). The rate of readmission was not different between normothermic patients and those with abnormal body temperature, except for higher readmission rate (12.2%) for patients with fever at 1SD from Tmax compared with normothermic patients (9.96%). Neither fever nor hypothermia was associated with shorter time to readmission, except for fever at 2 SDs from Tmax (10.6 days) compared with normothermic patients (12.6 days). Surprisingly, univariate analysis revealed that higher Tmax and older age were associated with lower readmission probability. Both uni- and multivariate analysis showed that the presence of fever is associated with lower readmission probability. Evaluating 200 individual cases, the most common explanation for body temperature abnormality was infection and 90% of the preventable readmissions were due to infection.

CONCLUSIONS

Abnormal body temperature 24 h prior to discharge was not useful for predicting the probability of readmission.

Ambulatory pulmonary artery pressure monitoring reduces costs and improves outcomes in symptomatic heart failure: a single center Canadian experience

Background

Pulmonary artery pressure (PAP) monitoring reduces heart failure (HF) hospitalizations (HFHs) and improves quality of life in New York Heart Association (NYHA) class III HF. We evaluated the impact of PAP monitoring on outcomes and health spending in a Canadian ambulatory HF cohort.

Methods

Twenty NYHA III HF patients underwent wireless PAP implantation at Foothills Medical Centre, Calgary, Alberta. Baseline, and 3-, 6-, 9-, and 12-month assessments of laboratory parameters, hemodynamics, 6-minute walk text and Kansas City Cardiomyopathy Questionnaire scores were collected. Healthcare costs 1 year pre- and post-implantation were collected from administrative databases.

Results

Mean age was 70.6 years; 45% were female. Results were as follows: an 88% reduction in emergency room visits (P = 0.0009); an 87% reduction in HFHs (P < 0.0003); a 29% reduction in heart function clinic visits (P = 0.033), and a 178% increase in nurse calls (P < 0.0002). Questionnaire and 6-minute walk test scores at baseline vs last follow-up were 45.4 vs 48.4 (P = 0.48) and 364.4 vs 402.8 m (P = 0.58), respectively. Mean PAP at baseline vs follow-up was 31.5 vs 24.8 mm Hg (P = 0.005). NYHA class improved by at least one class in 85% of patients. Mean measurable HF-related spending preimplantation was CAD$29,814 per patient per year and postimplantation was CAD$25,642 per patient per year (including device cost).

Conclusions

PAP monitoring demonstrated reductions in HFHs, and emergency room and heart function clinic visits, with improvements in NYHA class. Although further economic evaluation is needed, these results support the use of PAP monitoring as an effective and cost-neutral tool in HF management in appropriately selected patients in a publicly funded healthcare system.

Association between Intraoperative Blood Transfusion, Regional Anesthesia and Outcome after Pediatric Tumor Surgery for Nephroblastoma

BACKGROUND

Recent data suggest that anesthesiologic interventions-e.g., the choice of the anesthetic regimen or the administration of blood products-might play a major role in determining outcome after tumor surgery. In contrast to adult patients, only limited data are available regarding the potential association of anesthesia and outcome in pediatric cancer patients.

METHODS

A retrospective multicenter study assessing data from pediatric patients (0-18 years of age) undergoing surgery for nephroblastoma between 2004 and 2018 was conducted at three academic centers in Europe. Overall and recurrence-free survival were the primary outcomes of the study and were evaluated for a potential impact of intraoperative administration of erythrocyte concentrates, the use of regional anesthesia and the choice of the anesthetic regimen. The length of stay on the intensive care unit, the time to hospital discharge after surgery and blood neutrophil-to-lymphocyte ratio were defined as secondary outcomes.

RESULTS

In total, data from 65 patients were analyzed. Intraoperative administration of erythrocyte concentrates was associated with a reduction in recurrence-free survival (hazard ratio (HR) 7.59, 95% confidence interval (CI) 1.36-42.2, p = 0.004), whereas overall survival (HR 5.37, 95% CI 0.42-68.4, p = 0.124) was not affected. The use of regional anesthesia and the choice of anesthetic used for maintenance of anesthesia did not demonstrate an effect on the primary outcomes. It was, however, associated with fewer ICU transfers, a shortened time to discharge and a decreased postoperative neutrophil-to-lymphocyte ratio.

CONCLUSIONS

The current study provides the first evidence for a possible association between blood transfusion as well as anesthesiologic interventions and outcome after pediatric cancer surgery.

Characterizing the Association of Race and Insurance Status with Resource Utilization in Brachial Plexopathy Surgery

BACKGROUND

Understanding the link between socioeconomic status and immediate postoperative brachial plexus injury (BPI) management outcomes is critical to mitigating disparities and optimizing postoperative recovery plans. The present study aimed to elucidate the association between socioeconomic status and resource utilization following surgery for BPI.

METHODS

We conducted a cross-sectional study of adult patients (18 years) with a BPI diagnosis from the 2002-2017 National Inpatient Sample. Primary outcomes included home discharge rates, length of stay (LOS), and cost. We used multivariable regressions to analyze outcome measures.

RESULTS

A total of 23,755 BPI admissions were identified, 14.67% of whom received surgical intervention. Patients receiving Medicare had lower odds of home discharge compared with privately insured patients (adjusted odds ratio 0.65, 95% confidence interval 0.58-0.74; P < 0.001). Medicaid, Medicare, and uninsured patients had 6%-32% longer LOS than privately insured patients (P < 0.001, P = 0.004, and P = 0.006, respectively). Patients in the top income quartile had a 12% increase in costs compared with those in the bottom quartile (P < 0.001). Latinx and Other race groups had 11%-14% increased costs compared with White patients (Latinx P < 0.001, Other P = 0.003).

CONCLUSIONS

Differences in BPI resource utilization and allocation exist, from increased LOS among non-privately insured and non-White patients to increased BPI treatment costs among patients in higher-income quartiles. Further research is necessary to elucidate how these disparities exist and impact functional outcomes.

Association of Interprofessional Discharge Planning Using an Electronic Health Record Tool With Hospital Length of Stay Among Patients with Multimorbidity: A Nonrandomized Controlled Trial

IMPORTANCE

Whether interprofessional collaboration is effective and safe in decreasing hospital length of stay remains controversial.

OBJECTIVE

To evaluate the outcomes and safety associated with an electronic interprofessional-led discharge planning tool vs standard discharge planning to safely reduce length of stay among medical inpatients with multimorbidity.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter prospective nonrandomized controlled trial used interrupted time series analysis to examine medical acute hospitalizations at 82 hospitals in Switzerland. It was conducted from February 2017 through January 2019. Data analysis was conducted from March 2021 to July 2022.

INTERVENTION

After a 12-month preintervention phase (February 2017 through January 2018), an electronic interprofessional-led discharge planning tool was implemented in February 2018 in 7 intervention hospitals in addition to standard discharge planning.

MAIN OUTCOMES AND MEASURES

Mixed-effects segmented regression analyses were used to compare monthly changes in trends of length of stay, hospital readmission, in-hospital mortality, and facility discharge after the implementation of the tool with changes in trends among control hospitals.

RESULTS

There were 54 695 hospitalizations at intervention hospitals, with 27 219 in the preintervention period (median [IQR] age, 72 [59-82] years; 14 400 [52.9%] men) and 27 476 in the intervention phase (median [IQR] age, 72 [59-82] years; 14 448 [52.6%] men) and 438 791 at control hospitals, with 216 261 in the preintervention period (median [IQR] age, 74 [60-83] years; 109 770 [50.8%] men) and 222 530 in the intervention phase (median [IQR] age, 74 [60-83] years; 113 053 [50.8%] men). The mean (SD) length of stay in the preintervention phase was 7.6 (7.1) days for intervention hospitals and 7.5 (7.4) days for control hospitals. During the preintervention phase, population-averaged length of stay decreased by -0.344 hr/mo (95% CI, -0.599 to -0.090 hr/mo) in control hospitals; however, no change in trend was observed among intervention hospitals (-0.034 hr/mo; 95% CI, -0.646 to 0.714 hr/mo; difference in slopes, P = .09). Over the intervention phase (February 2018 through January 2019), length of stay remained unchanged in control hospitals (slope, -0.011 hr/mo; 95% CI, -0.281 to 0.260 hr/mo; change in slope, P = .03), but decreased steadily among intervention hospitals by -0.879 hr/mo (95% CI, -1.607 to -0.150 hr/mo; change in slope, P = .04, difference in slopes, P = .03). Safety analyses showed no change in trends of hospital readmission, in-hospital mortality, or facility discharge over the whole study time.

CONCLUSIONS AND RELEVANCE

In this nonrandomized controlled trial, the implementation of an electronic interprofessional-led discharge planning tool was associated with a decline in length of stay without an increase in hospital readmission, in-hospital mortality, or facility discharge.

TRIAL REGISTRATION

isrctn.org Identifier: ISRCTN83274049.